Humans animals, plants, insects, bacteria and viruses that may never have left one geographic area for another are now moving every day around the world. This movement can cause animal health syndromes that may not have been seen in some areas, or isolated cases may not be connected to other cases that have occurred elsewhere.

Syndromic surveillance - a key to disease monitoringBut that’s changing. A unique program is being piloted in the states of New Mexico and Texas that is equipping practitioners with tools for reporting a variety of animal health conditions and then relaying that information, analyzing it and reporting it in near real-time.

“Surveillance is one action used to help protect countries from unnecessary trade restrictions,” says Tom Hairgrove, DVM, Texas A&M AgriLife Extension Service. ”The primary objective of surveillance is to ‘intentionally seek out as early as possible the target agent of disease cases or to identify the elevated risk in order to maximize prevention, treatment, and control, or the likelihood of eradication and to minimize the impacts of the disease’.”

In 2010, New Mexico Cooperative Extension approached Texas A&M AgriLife Extension Service about the possibility of collaboration with their syndromic surveillance program. The National Center for Foreign Animal and Zoonotic Disease Defense (FAZD Center), Texas Center for Applied Technology (TCAT, a part of the Texas A&M Engineering Experiment Station) , Texas A&M Veterinary Medical Diagnostic Laboratory (TVMDL), Texas A&M University College of Veterinary Medicine, USDA and Texas A&M AgriLife Extension Service are currently working together to implement this pilot program in Texas and bring both states on board with a real-time reporting system. The program is a seedling effort, funded by the Homeland Security Advanced Research Projects Agency within the U.S. Department of Homeland Security’s (DHS) Science and Technology Directorate. The FAZD Center is a DHS Science and Technology Center of Excellence.

FAZD Center/TVMDL epidemiologist Lindsey Holmstrom, DVM, says that this surveillance pilot is non-disease-specific and is designed to detect anomalies in animal health that may warrant further investigation and specific diagnosis through the collection and analysis of specific body system associated clinical signs, or syndromes, in animal populations.

Using the ALIRT concept
In 2006 the New Mexico Ag/Livestock Incident Response Team (NM-ALIRT) was modeled after the Arizona Livestock Incident Response Team (ALIRT) concept (see Training to Respond, Bovine Veterinarian, February 2008). “This program is a network of veterinary practitioners scattered around New Mexico whose practices consist of some level of food animal practice,” explains New Mexico State University (NMSU) Extension veterinarian John Wenzel, DVM, who is also the NM-ALIRT state coordinator.

“These veterinarians have been equipped and trained to respond to a large or suspicious livestock loss occurring in New Mexico,” he says. “The role of the ALIRT veterinarian is to gather and process a history and diagnostic specimens as quickly as possible to hopefully determine a cause for the livestock loss. Later, a syndromic surveillance component was developed and added with assistance and funding from USDA.”

Syndromic surveillance - a key to disease monitoringThe NM-ALIRT veterinarians kept track of particular syndromes by specie, including respiratory, digestive, sudden death, toxicity, CNS/musculoskeletal, reproductive and vesicular disease. Wenzel says the tally was faxed monthly from each practitioner to the state coordinator, but it became too cumbersome to maintain so a web-based reporting system was developed by NMSU. “This became more convenient and then Arizona veterinarians began to report into the system.” The USDA-APHIS-Veterinary Services National Surveillance Unit provided financial assistance for the program’s expansion, which then included Texas.

FAZD Center Director Tammy Beckham, DVM, PhD, says a significant step in moving the project forward came through a collaboration between the FAZD Center and the TCAT.

“Our centers developed two products that work in unison,” Beckham says. “One is a data-sharing technology we call AgConnect. The other is a related iPad application that allows for real-time reporting and data analysis, which we call the Biosurveillance Field Entry System (BFES). Without these products, it would be very difficult to succeed with this project.”

Texas A&M System Chancellor John Sharp adds that the product development illustrates how well the agencies of the Texas A&M University System work together to tackle major challenges.

“We have the FAZD Center, a part of Texas A&M AgriLife Research, working closely with the Texas A&M Veterinary Medical Diagnostic Laboratory to apply technology developed at TCAT, which is part of the Texas A&M Engineering Experiment Station,” Sharp says. “The result is a data-sharing tool that will help to make our nation a safer place to live.”

Working together, the FAZD Center, TCAT, the DHS, the USDA, and NMSU have now instituted the Enhanced Passive Surveillance (EPS) pilot program for cattle and small ruminants (see sidebar).

Wenzel notes, “The training the ALIRT veterinarians receive concentrates on foreign animal disease detection, toxicities associated with large livestock loss, terrorism threats, crime scene preservation and diagnostic lab specimen collection, handling and shipping. They take their role as first responders very seriously and have been very willing participants. With the training they have received, they understand the need to be always vigilant to protect the livestock industry.”

Hairgrove adds that the data has been useful in allowing practitioners to observe spatial and temporal trends in disease syndromes in both states.

“Traditionally, animal surveillance programs have focused on disease- and agent-specific detection with confirmed laboratory diagnosis,” Holmstrom says. “Typical surveillance programs are limited in disease scope and can miss important disease events and trends.”

Holmstrom adds that it is anticipated that a properly developed, comprehensive EPS system will provide early detection of endemic, zoonotic, transboundary, environmental, and newly emerging animal diseases.

“Veterinary practitioners are the first line of defense for diagnosing emerging disease conditions,” says Texas State Veterinarian Dee Ellis, DVM, MPA. “In that context, the syndromic surveillance concept is complementary to the ‘reportable disease’ responsibility and role that veterinarians already participate in with animal health, public health and diagnostic laboratories across the nation.”

Robert Conley, DVM, Conley Veterinary Services, Vernon, Texas, is one of the practitioners participating in the pilot surveillance program. “The program allows me to watch my reports for any trends in my practice,” he says. “This is useful for me to watch for disease trends I might have overlooked due to the spread out nature of my practice.” The geographic feature of the reports helps Conley watch his entire area in one simple concise location, which is helpful as his practice radius is about 160 miles east to west and 120 miles north to south.

Gary Warner, DVM, Elgin Veterinary Hospital, Elgin, Texas, sees the most value in the ability to see a disease or toxicological event occur before most would realize if there were larger numbers of veterinarians reporting. “I can see this as an avenue for practitioners to see cases, take pictures/video, give vitals and clinical signs, and then post to ask colleagues for an immediate opinion as to what may be occurring in real time,” Warner says. “The concept is great, the iPad is extremely user friendly and the platform software is good.”

Surveillance streams
Practicing veterinarians aren’t the only ones submitting data. Surveillance streams include data from them as well as the livestock markets in New Mexico, veterinary diagnostic laboratories in New Mexico and Texas, and wildlife information sources from veterinarians and diagnostic laboratories.

The EPS System builds on data streams that currently exist, Holmstrom says. “We are not creating new streams, but rather we have developed the tools and mechanisms to collect these data in real-time to allow animal health officials, public health officials, and veterinarians to respond more quickly and make more informed decisions.”

All information is compiled and kept anonymous so no producer or particular ranch information is included in the reporting process, Wenzel adds. Reports are submitted by the veterinary practitioner with only the county disclosed.

How data are shared
The EPS analyst workstation aggregates the incoming data streams into a common integrated picture and allows for further data display and analyses by state and federal government epidemiologists/analysts. Reports of these analyses can be made available to industry and veterinarians for animal health management.

A Summary Report section within the BFES iPad app was developed that includes tabular, graphical, and geographical displays of both the veterinarians’ own submitted data and data submissions from other participating veterinarians within their own state rolled up to the county level.

“Being able to view data submitted by veterinarians in a participant’s own state increases his or her situational awareness of the animal health status within his or her region or state,” Holmstrom says. “These data can be filtered for customized data display, such as by date range, species or syndromes. Veterinarians can also access their previous submissions.“

Holmstrom adds that they are currently looking into developing an electronic newsletter that will be made available to stakeholders and include information on overall distribution and trends in syndromes and disease issues reported by networkparticipants.

“It cannot be overstated that the success and sustainability of this project and future expansion of the EPS to other agricultural industries and regions is based on identifying incentives for participants to want to use the reporting tools such as the iPad in addition to the BFES app, and see the usefulness of the overall system,” Holmstrom states. Some of the incentives currently being offered and those that are planned for future expansion include: providing useful information back to iPad users in real-time, linking diagnostic test results submitted through the system back to the BFES reports, and linking with electronic health certificate submissions.

At the veterinarians’ request, a forum for sharing information with other practicing veterinarians within the BFES app via the web was also developed. “The reason we went with developing an iPad app, and not having the reporting exclusively web-based, was so that reports could be entered in the field at the time and location the animal(s) is seen by a veterinarian, even when there is no connectivity,” Holmstrom says. “Reports are queued on the iPad and immediately submitted once the iPad comes back into connectivity.”

“The iPads and apps are extremely easy to work with and userfriendly,” Conley says. “All reports are basically fill-in-the-blanks to a point then you have the ability to type in any additional information that may be important to the case. The ability to report even when there is no service for the internet is useful because much of my practice is completed on ranches where cell service is not always reliable. This does not take time out of my day to keep up with. If this required a more labor intense process it would be much more difficult to report every day; therefore, possibly important events could be easily left out.”

The EPS system relies on reporting by veterinarians in addition to the EPS System integrating data streams from other sources, Holmstrom stresses. “It is incredibly important that veterinarians see the value, usefulness and benefits of the EPS System for it be successful and sustainable.”

What the data shows so far
The pilot project is estimating baseline prevalence rates of observed animal health anomalies for each stream that can be used as benchmarks to then detect higher than expected incidents of adverse animal health (signals) in near-real-time. Holmstrom says it is expected that it will take a year or longer time period of data collection for baseline levels to be determined.

“We are evaluating the significance of resulting signals as disease detection events by corroborating signals with one or more of the other surveillance streams,” she says. “The goal is to provide early warning information obtained from validated signaling activity to stakeholders to assist in making decisions that reduce the cost of disease outbreaks, protect our public health sector, and enhance disease prevention activities.”

There have not been any animal health threats/outbreaks reported since the pilot project initiated in July 2012. Holmstrom says veterinarians also report on healthy animals, which help demonstrate disease freedom to US trading partners. The uniqueness of the EPS is the power to aggregate data, Wenzel adds. A series of unremarkable findings in a region may have great significance when collated and viewed by a veterinary epidemiologist.

“We are trying to continually make the program better,” Holmstrom says, “and will continue providing useful information for industry and private practitioners, with their input, for animal health management. We want to reward participation and incentivize veterinarians by facilitating data sharing, communication, and increasing their awareness of animal health status in their geographic area.”

“There is a distinct advantage for future veterinarians in our industry as they will be able to communicate about possible disease concerns much more easily, gain more insight from colleagues and possibly make better decisions about dealing with those cases,” Warner adds.

“Surveillance is extremely important,” Conley states. “It could be the only means by which we lessen the effects of, or halt a major disease outbreak. This program allows us to all work together (veterinarians, diagnostic labs, universities, etc) in one place to prevent/lessen a disease outbreak.”

Conley believes food animal veterinarians must participate in programs like this. “As there are fewer of us practicing primarily large animal/ food animal medicine, we have inevitably become more spread out and are serving larger areas. This will allow us to communicate in almost realtime much more quickly than conventional channels.”

Continuing education is paramount in disease surveillance and appropriate CE will be provided to participating pilot practitioners, Hairgrove adds. “This program is in its infancy and an evolving process. We encourage constructive evaluations and input from all concerned as this pilot program goes forward.”


Sidebar: Surveillance uses app technology
For the pilot syndromic surveillance program, veterinarians report into the Enhanced Passive Surveillance (EPS) System via the Biosurveillance Field Entry System (BFES) iPad app. A web-based version of the BFES app was also developed, which provides an alternative for those individuals who would like to provide data as part of the project, but do not have access to an iPad or where mobile entry is not needed.

Both the iPad app and web-based reporting tools are of the same format for the information and data that are collected. “The app was developed in close collaboration with large animal veterinarians who are part of this project to ensure its usability,” says Lindsey Holmstrom, DVM.

Once submitted, the information/data are immediately sent to the EPS analyst workstation, which aggregates the incoming data-streams into a common integrated picture and allows for further data display and analyses by epidemiologists/ analysts. Data can also be stored on the device for transmission once the user comes in to a cellular data footprint, a capability that would not be possible with strictly web-based reporting. The EPS analyst workstation is updated in near real-time as data are submitted by veterinarians.

Information/data are sent in via the BFES app or web-based reporting tools. “We currently have 44 iPad users reporting across Arizona, New Mexico and Texas,” Holmstrom says. “We are averaging between 230-260 reports per  week.”

The format is very user-friendly and a user’s manual was developed, which can be viewed on the iPad, to provide further explanation of the data displays and capabilities for viewing a user’s own data and the data within his/her own state.

To make the program more widely used, they are currently looking into making the BFES app compatible on other mobile platforms (e.g. Android, iPhones) and distributing the app in various App stores (e.g., Apple Store, Google Play). A web-based reporting capability has already been developed.

“We have consistent communication with iPad users to receive feedback on the ease of use of this reporting tool, identify and resolve potential problems, and ensure reporting compliance,” Holmstrom says. A helpdesk was established at the Texas A&M Veterinary Medical Diagnostic Laboratory (TVMDL) where BFES users can call and get technical support on any issues, as well as provide feedback on system usage.